Note: Psychotherapy is sometimes used in combination with drugs or herbal medicine to help alleviate psychological symptoms. This monograph pertains primarily to psychotherapy as a modality in itself and does not evaluate related drugs or herbs. We do, however, note some circumstances where combined therapy is recommended or where psychotherapy should not be relied upon alone.

Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Its purpose is the exploration of thoughts, feelings, and behavior for the purpose problem solving or achieving higher levels of functioning.

Psychotherapists are bound by professional and legal standards of ethics, such as protecting the confidentiality of information provided by clients or patients, not engaging in inappropriate behavior with a client or patient, and protecting the safety of children by reporting suspected child abuse to legal authorities.

The generally acknowledged father of modern psychotherapy was Sigmund Freud, a neurologist in 1880s Vienna, Austria, who noted that some of his patients did not seem to have a physical cause for their symptoms. Freud became intrigued with the relationship between the mind and physical symptoms. In 1886, he opened an office for the practice of what he named "psychoanalysis," which incorporated dream interpretation, free association, and the three levels of consciousness: the id (primitive drives and impulses), the ego (normal waking mental functioning), and the superego (conscience, self-regulation of right and wrong).

Psychoanalytic theory is one of four major approaches to psychotherapy. The others are behavioral (primarily concerned with behavioral processes and outcomes), humanistic (focused on existential issues, meaning, and self-actualization), and transpersonal (focused on transcendent awareness and the spiritual dimensions of life). These four main approaches are blended in many different varieties of psychotherapy.

To define diagnoses and symptoms of mental disorders, the American Psychiatric Association published the first Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 with around 60 disorders. The DSM was last revised in 2000, creating the DSM-IV-TR. This is the standard reference used by psychotherapists and the healthcare system for defining and describing mental disorders and symptoms. The next revision of the DSM is scheduled for 2011 or later.

Psychotherapy is conducted in private individual, couple, group, or family sessions. Generally, sessions range from 50 minutes for individuals to 90 or 120 minutes for groups. The number of sessions varies widely depending on the problems being addressed and the context (outpatient, inpatient, payment source). "Brief therapy," the approach preferred by health insurance companies that cover mental health services, is generally defined as up to eight sessions. The opposite extreme, psychoanalysis, may be multiple times per week over several years.

The cost of a psychotherapy session depends on several factors, including the type of therapy, the education and experience of the therapist, and the geographical location. An hour of therapy may range from $5 or $10 an hour at a community or non-profit mental health center to over $200 an hour for a doctoral level practitioner in private practice.

People who have received professional training in psychotherapy include psychiatrists, clinical psychologists, clinical social workers, marriage and family counselors, and some pastoral counselors. A psychiatrist is a board-certified physician (M.D. or D.O.) with a four-year residency in psychiatry. Unlike other therapists, psychiatrists can prescribe medications. Clinical psychologists have at least a master's degree and usually a doctoral degree and are licensed by the state. Clinical social workers as well as marriage and family therapists/counselors have at least a master's degree and are licensed by the state. Some states have other designations for licensing purposes (e.g., mental health counselor or clinical professional counselor). In all cases, a license requires a number of hours of supervised experience beyond the professional degree, the passing of an exam, and periodic continuing education courses.

Pastoral counselors may have minimal to extensive training in psychotherapy. They may or may not be licensed by the state and practice under the auspices of being clergy.

Psychotherapists may have extensive training in a specific type of psychotherapy or multiple types. They may also specialize in working with a certain age group (children, adults, elderly) or with people with a certain type of problem (e.g., mental illness, coping with medical illness, marital and family relations, domestic violence or abuse, educational functioning, substance abuse).

These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Psychodynamic group therapy and cognitive-behavior group therapy may reduce aggression in male veterans with a history of committing assault.

B

Individual, group, and family therapy may help aggressive youth reduce the severity of anger problems.

B

Psychotherapy may improve outcome, prevent relapse, improve sexual and social adjustment, and encourage weight gain in patients with anorexia nervosa.

B

Family psychotherapy may slightly improve wheezing and thoracic gas volume for children with asthma.

B

Child-parent psychotherapy may improve quality of attachment (ability of young children to bond or interact appropriately) and social-emotional functioning of anxiously attached infants and toddlers of depressed mothers. Preventative psychotherapy for parents might reduce occurrence of impaired neurological development of very low birth weight, premature infants.

B

Psychotherapy, especially cognitive behavioral therapy, may help bulimics reduce binge eating, purging and relapse, and improve dietary restraint and attitudes towards body shape and weight. Prescription medication may be used with psychotherapy, but may not be as successful alone.

B

There is good evidence that psychotherapy can enhance cancer patients' quality of life by reducing emotional distress and aiding in coping with the stresses and challenges of cancer. Therapy may be supportive-expressive therapy, cognitive therapy, or group therapy. Studies conflict on whether therapy improves self-esteem, death anxiety, self-satisfaction, etc. While some patients seek psychotherapy in hopes of extending survival, there is no conclusive evidence on its effects on medical prognosis.

Group therapy may reduce the risk of postpartum depression in high-risk women. Psychotherapy plus standard antenatal care may reduce the occurrence of depression for up to three months. Interpersonal psychotherapy may be an effective method in treating antepartum and postpartum depression, particularly for women who are breastfeeding and cannot use pharmacotherapy.

B

Psychotherapy may help treat depressed adolescent patients. Cognitive behavior therapy may be more effective for depressed adolescents than other types of therapy.

B

Psychotherapy may be beneficial for patients with dysthymia (chronic low-grade depression). Group therapy may be as effective as individual therapy. However, in more severe cases, medication is also recommended.

B

Psychotherapy may help treat seniors with depression. In some cases, prescription anti-depressants with psychotherapy may be helpful.

B

A broad range of psychotherapies are effective for the treatment of depression, including behavior therapy, cognitive-behavioral therapy, and interpersonal therapy. Brief dynamic therapy, marital therapy, and family therapy may work best, depending on the patient's problems and circumstances. Prescription medication may also be helpful for persistent, recurring depression.

B

Psychotherapy may be successful in treating mild to moderate depression. In more severe cases, psychotherapy is best accompanied by prescription medication.

B

Psychotherapy, especially cognitive behavioral therapy, may decrease the symptoms of generalized anxiety disorder. Treatment may also include prescription medication.

B

Behavioral marital therapy and insight-oriented marital therapy may decrease marital distress. Marital therapy in conjunction with anti-depressants may also be helpful for depressed people.

B

Behavioral and cognitive-behavioral therapy used with prescription medications may lead to substantial improvement. However, a patient may still have moderate OCD symptoms, even following adequate treatment.

B

Psychotherapy, especially cognitive behavioral therapy, may help patients with panic disorder. Prescription medications may also be helpful in some cases.

B

Various forms of cognitive behavior therapy may be very helpful for patients with posttraumatic stress disorder. Group therapy may not be as effective as individual therapy.

B

Although group therapy may somewhat decrease pain in people with rheumatoid arthritis and depression, individual therapy coupled with anti-depressants may be more effective.

B

Although prescription medication is usually the best way to help patients with schizophrenia, psychotherapy, especially cognitive therapy, may greatly enhance coping, social skills training, social functioning, and quality of life, at the same time reducing psychotic relapse and re-hospitalization.

B

Women with post-traumatic stress symptoms related to childhood sexual abuse may decrease their symptoms slightly more with cognitive-behavioral therapy than present-centered therapy.

B

Psychotherapy may be helpful for children who are sexually abused. Group therapy and individual therapy may be equally effective, although individual therapy may address post-traumatic stress symptoms more effectively.

B

Psychotherapy may be very effective at reducing repeated attempts at suicide, suicidal thoughts, and depression. However, different mental illnesses may respond better or more quickly to a specific type of psychotherapy.

B

Several studies indicate that people who are overweight or obese may benefit from behavioral and cognitive-behavioral psychotherapy in combination with diet and exercise.

B

Several studies indicate that psychotherapy in the elderly may improve psychological well-being and decrease self-rated depression, especially for those in individual therapy.

B

Psychotherapy, or a combination of psychotherapy and prescription medication, may help alcohol abuse patients prevent relapse, overcome withdrawal symptoms, and deal with underlying problems, depression, or anxiety.

C

Alexithymia, or the inability to express one's feelings, may influence the course of coronary heart disease (CHD). Educational sessions and group psychotherapy may decrease alexithymia and reduce cardiac events.

C

Children ages 8-15 who maintain active involvement in therapy may respond well to cognitive-behavioral psychotherapy. More study is needed in this area.

C

Atopic dermatitis is a skin disease associated with an increased anxiety level. Psychotherapy may be helpful for atopic dermatitis patients with high levels of anxiety.

C

One small trial showed that psychotherapy may be more effective than either a bed-wetting alarm or rewards in terms of children failing or relapsing. In another study, psychotherapy and a placebo was just as effective as psychotherapy combined with piracetam and diphenylhydantoin, suggesting that psychotherapy may be used before drugs.

C

Prescription medication is the most effective treatment for bipolar disorder. Psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.

C

Psychotherapy may help patients with borderline personality disorders. Both schema-focused therapy and transference-focused psychotherapy may be helpful psychotherapy techniques. These patients usually need one to three years of therapy before they begin to see clinical improvement.

C

Cognitive behavioral psychotherapy and cognitive remediation appear to lessen psychological distress and improve cognitive functioning among patients with traumatic brain injury. More study is warranted in this area.

C

Psychotherapy for patients with COPD may decrease anxiety and depression, but it does not seem to improve physical performance.

C

Child therapy may improve children's language proficiencies, and individual therapy may be more successful than group therapy. Further research in this area is needed.

C

Psychotherapy may not improve the course of Crohn's disease, although patients undergoing psychotherapy tended to have fewer operations and relapses. More research in this area is needed.

C

Telephone-administered cognitive-behavioral therapy may help treat depressed multiple sclerosis patients, although more study is needed in this area.

C

Psychotherapy may help treat substance-dependent depressed patients, but combining psychotherapy and prescription medication may be helpful in patients failing to respond to psychotherapy alone.

C

Psychotherapy may improve blood sugar control in teens and adults with poorly-controlled type I diabetes, especially if blood sugar problems are related to depression. However, more studies are needed to confirm this.

C

Cognitive behavior therapy may reduce depression and improve blood sugar level control in patients with type II diabetes. Therapy may be less effective in people with diabetes complications or poorly-controlled blood sugar levels. More studies are needed to make definitive recommendations.

C

Psychotherapy, especially cognitive behavioral therapy, may help patients stop drug use and reduce relapses. Combination treatment of psychotherapy and certain medications is sometimes more effective than psychotherapy alone. Group therapy may be more effective than individual therapy.

C

Short-term cognitive psychotherapy may not reduce the long-term recurrence of duodenal ulcers. More research is needed in this area.

C

Psychodynamic-interpersonal psychotherapy therapy or cognitive psychotherapy may improve dyspepsia symptoms, both short- and long-term, in patients with mild to moderate dyspepsia, but further evaluation is required.

C

Supportive psychotherapy may reduce psychiatric symptoms of patients with emphysema. More research needs to be done in this area.

C

Individual, couples, or group psychotherapy may be helpful for men with erectile dysfunction. However, prescription medication may be needed to alleviate symptoms.

C

Psychotherapy may help patients deal with mourning and mental health issues associated with major grief. In severe cases, prescription medication may also be recommended in combination with psychotherapy with grief-related depression.

C

Psychotherapy, especially supportive psychotherapy, may reduce depression or coping in HIV-positive patients. It may also help with treating substance abuse when used in combination with prescription medicine. Supportive-expressive group therapy may also have concomitant improvements in CD4 cell count and viral load. More research is needed in this area, especially to determine the best type of psychotherapy.

C

Psychotherapy, especially cognitive behavior therapy, may improve pain-related functioning in people with HIV-related peripheral neuropathic pain. More research needs to be done in this area.

C

Group and individual/couple psychotherapy may reduce depression and anxiety associated with infertility. However, psychotherapy may not improve fertility rates. More and better-designed studies are needed in this area.

C

Psychotherapy may increase IBS patients' tolerance to rectal distension, improve health-related quality of life, and reduce stomach pain and diarrhea. Hypnotherapy may be more successful than other forms of psychotherapy in improving IBS symptoms. Medications for depression may also be helpful for depressed patients with IBS. More studies are needed in this area.

C

Although individual and group psychotherapy may decrease depression associated with a kidney transplant, individual therapy may be more effective than group therapy. More research needs to be done in this area.

C

There is conflicting evidence as to whether or not brief supportive-expressive group psychotherapy reduces psychological distress and medical symptoms and improves the quality of life of women with systemic lupus erythematosus (SLE). Further studies are needed to draw clear conclusions.

C

Psychotherapy, including group therapy and individual cognitive-behavioral therapy, may reduce major depression in multiple sclerosis patients and improve their quality of life. More research is needed to verify these preliminary results.

C

There is insufficient evidence to confirm the efficacy of psychological intervention in NUD.

C

Psychotherapy may reduce pain, including chronic pain, low back pain, and pain associated with pelvic congestion. In some cases, psychotherapy combined with medication may be more effective. More research needs to be done in this area.

C

Preliminary studies suggest that psychodynamic therapy and cognitive behavior therapy may be more effective treatments of personality disorders than other forms of psychotherapy. Personality disorders are difficult to treat but may respond to psychotherapy with a well-trained clinician who specializes in this area.

C

Cognitive behavioral therapy involving exposure to phobic stimuli, and focused on changing phobic thinking, benefits many patients, both at the end of treatment and after treatment. Exposure-based therapies are the most successful for phobic disorders. Prescription medication may be used along with therapy. More studies are needed in this area.

C

Based on one study, cognitively oriented psychotherapy for early psychosis (COPE) showed no beneficial treatment effect over the Early Psychosis Prevention and Intervention Centre (EPPIC). More study is needed to draw a firm conclusion.

C

Short-term psychotherapy for psychosomatic conditions may not be as effective as long-term. More research needs to be done to evaluate these approaches.

C

Psychotherapy may help seasonal affective disorder. Further study is needed to confirm early results.

C

Brief personal construct psychotherapy may be effective for people who self-harm and merits further exploration.

C

Several studies suggest that group therapy may be more effective than self-help for quitting smoking. However, there is not enough evidence to show that group therapy is as effective or cost-effective as intensive individual counseling. More research is needed to determine effectiveness.

C

Studies show mixed results about the efficacy of cognitive behavioral psychotherapy for depression following stroke. More research needs to be done in this area.

C

Supportive psychotherapy may or may not reduce the motor and vocal tics associated with Tourette's syndrome. More research needs to be done before recommendations can be made.

C

People with detrusor instability or sensory urgency may benefit from psychotherapy and reduce urgency, incontinence, and nighttime urination, but probably not overall frequency. More research is needed in this area.

C

Based on one study, brief psychotherapeutic approaches dos not help improve cognitive function and overall well-being in Alzheimer's disease patients. More studies are needed in this area.

D

Psychotherapy may not improve parenting, enhance academic achievement, or improve emotional adjustment for children ages 7-9 with ADHD. It is unclear whether psychotherapy will reduce the use of stimulants, such as methylphenidate, in these children. More studies are needed in this area.

D

Several studies suggest that patients with psychotic depression are probably not good candidates for psychotherapy and that medication remains the optimal treatment. More research is needed to determine how psychotherapy might be of benefit in psychotic depression.

D

* Key to grades

A: Strong scientific evidence for this useB: Good scientific evidence for this useC: Unclear scientific evidence for this useD: Fair scientific evidence for this use (it may not work)F: Strong scientific evidence against this use (it likley does not work)

Tradition / Theory
The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.

Safety
Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes.

In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner.

Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist.

Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions.

Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Borkovec TD, Sibrava NJ. Problems with the use of placebo conditions in psychotherapy research, suggested alternatives, and some strategies for the pursuit of the placebo phenomenon. J Clin Psychol 4-12-2005;61(7):805-818.

Psychotherapy is often accompanied by treatment with drugs to help reduce psychological symptoms. This requires supervision by a psychiatrist or physician, as the other mental health disciplines cannot prescribe drugs.

Drugs may reduce the need for psychotherapy. Effective psychotherapy may reduce the need for drugs, or may make lower doses, and hence fewer side effects, possible.

Drugs may interfere with the effectiveness of psychotherapy if mental functioning is impaired as a side effect of the drug. This applies to both psychiatric medications and medications for medical conditions.

Some forms of medication for medical conditions (prescription and over-the-counter) have psychological or emotional side effects such as anxiety, depression, impaired cognitive functioning, or impaired sleep. These problems may be better treated by modification of dosage of the medication rather than psychotherapy. Patients should speak with a doctor about side effects of medications and adjusting dosage to reduce side effects if possible.

Interactions with Herbs and Dietary Supplements

Certain herbs are reputed to be beneficial for mental health conditions (e.g., St. John's wort/hypericum for depression). When used properly, these may reduce the need for psychotherapy. However, herbs and prescription medications can interact and have adverse effects, including exaggerating or interfering with each other's effects. They should not be mixed without consultation with a qualified healthcare professional.

Like drugs, some herbs may also have psychological or emotional side effects. These may be better treated by reducing use of the herb rather than pursuing psychotherapy.

People interested in using herbs with psychotherapy should inform the therapist of this. Depending on the seriousness of the condition, referral to a psychiatrist may be recommended to monitor the use and effects of herbs and determine whether medication may be more appropriate.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.